Approved by OMS -3060-0096Expires 07/31/93See page two for informationregarding public burden estimate.Application for Ship Radio Station LicenseA. CHECK BLOCK "A" ONLY IF SHIP IS RECREATIONAL OR VOLUNTARILY EQUIPPED. Complete applicable items 1thru 13and signapplication. You will automatically be authorized for VHF (156-158 MHz) & Class C EPIRB (156.75-156.8 MHz). Additional equipment otherthan VHF & EPIRB must be requested in Item 16.B. CHECK BLOCK "B" ONLY IF SHIP IS COMPULSORY EQUIPPED (REQUIRED TO BE RADIO EQUIPPED). Complete applicableitems I thru 18 and sign application. You will only be authorized for the specific category of transmitters that you have checked in Item 16. (Seeinstruction 16) '.1. Type of Applicant (Ckleck only one)§(A) Association I 14. ShipD (I) Individual . (P) PartnershipD (C) Corporation (G) Governmental Entity2. ApplicanVLicensee Name (See instruction)FEDERALCOMMUNICATIONSCOMMISSIONDDDBAName (See instruction)3. MailingAddress (Number and Street, P.O. Box or Rt. No.)City State ZIP Code4. Additional Partners5. Purpose of ApplicationD New Station D Modification D Renewal6. Type of License{Check o~one)D (R) Regular U (F) Fleet (No. of ships) -D (P) Portable (Give required showing)7. Name of Ship (See instruction)8. Official Number of Ship (Coast Guard Documentation No. or StateRegistration No.): If none, see instruction.9. Call Sign (See inst.ruction)10. Class of Ship (See instruction)(~) General: (B) Specific:11. Relationship of Applicant to Ship (Check only one)D (A) Owner and/or OperatorD (B-)Other (Specify)12. International Communications: (See instruction)(A) Will Ship make international voyages?(B) Will Ship communicate with foreign coast sta-tions other than those located in Canada or Mexico?13. (A) Are you requesting a Ship Station Identity(9 digit number) to be used with Digital SelectiveCalling Equipment?(B) Have you been assigned a Ship Station Iden-tity Number for,this Ship?If YES, show numberadioRequirementCategories(Seeinstruction) ,D (A) Radiotelegraph Station Required by Title Ill, Part 11oftheCommunications Act or Safety of Life at Sea Convention.D (B) Radiotelephone Station Required by Title Ill, Part 11of theCommunications Act or Safety of Life at Sea Convention,D (C) Radiotelephon~ Station Required by Title Ill, Part III of theCommunications A~t.0 (D) Radiotelephone Station Required by the Great Lakes Radio, Agreement.D (E) Radiotelephone Station Required by the Vessel Bridge- To-Bridge RadiotelephoneAct.15. Gross Tonnage and/or Len!;}th of Ship (See instruction)(A) Gross Tons: (B) Feet:16. Category of Transmitters (See instruction}Check No. (Categories)VHF/FM Radiotelephone(I 56-158MHz)& EPIRB(156.75-156.8MHz)EPIRB (121.5and/or 243 MHz) ClassA,B. or SSSB Radiotelephone(1600-4000 kHz)SSB Radiotelephone(4000-23000kHz)Radar (2900-3100MHz) and; or (9300-9500MHz)Radar (14.0-14.05GHz)Radiotelegraph(2000-27500kHz) Except Direct PrintingRadiotelegraph(2000-27500kHz) Direct Printing (NBDP/SITOR)Radiotelegraph(405-535kHz)Survival Craft (500 kHz) (8364kHz)RTTY-Radioprinter (Under 1600GrossTons)AMTS (216-220MHz)FacsimileSatellite (16365-1644MHz)EPIRB (1645.5-1646.5MHz)EPIRB (406-406.1MHz)On-Board (457.525-467.825MHz)OTHER (Seeinstruction)17. Radiotelegraph Morse Working Channel Series(2000-27500 kHz):W_-,W_-18. Numerical ShipcStation Identification(A) Selective Call .Number (5 digits)(B) INMARSATNumber (7 digits)CERTIFICATION, READ CAREFULLY BEFORE SIGNING1. Applicant waives any claim to the use of any particular frequency regardless of prior use by license or otherwise.2. Applicant will have unlimited access to the radio equipment and willcontrol access to exclude unauthorized persons.3. Neither applicant nor any member thereof is a foreign government or representative thereof. .4. Applicant certifies that all statements made in this application and attachments are true, complete, correct and made in good faith.5. Applicant certifies that the signature is that of the individual, or partner, or officer or duly authorized employee of a corporation,or officer who is amember of an unincorporated association, or appropriate elected or appointed official on behalf of a governmental er:'tity.WILLFULFALSESTATEMENTSMADEONTHISFORMAREPUNISHABLEBYFINEAND/ORIMPRISONMENT.U.S.CODETITLE18,SECTION1001Typed/Printed Signor Name:Signature:Telephone No:Date:FCC Form 506, Page 1February 1991YES NOD DD DYES NOD DD D